Every finding on record at Clay Center Presbyterian Manor

Based on observation, interview, and record review, the facility failed to serve food in a sanitary manner for the 29 residents who received food from the facility kitchen. Findings included:- On 07/06/2026 at 12:25 PM, observation revealed Certified Nurse Aide (CNA) M brought her ponytail to the front of her body and stroked it up and down with both hands approximately three times, then flung the ponytail to the back of her head and did not wash hands or use hand gel. Continued observation revealed CNA M delivered a resident plate of food to the table, then returned to the kitchenette and obtained another plate of food and delivered that plate to another resident. Continued observation revealed CNA M tied her scrub pants with both hands and did not wash hands or use hand gel and delivered a plate of food from the kitchenette, then returned to the kitchenette and got a small glass of thickened liquid and grabbed it by the top of the cup and touched the lip surface with her hand before she delivered the cup to the resident. CNA M grabbed a rolling stool and pushed it next to a resident and assisted her to eat a few bites of pureed food. Continued observation revealed at 12:40 PM, CNA M brought her ponytail to the front of her body and stroked it up and down with both hands approximately two times, then flung the ponytail to the back of her head and did not wash hands or use hand gel. She obtained a clothing protector and delivered it to another CNA to place on a resident before they ate their lunch. Continued observation of the meal service revealed CNA M did not wash her hands or use hand gel throughout the meal service. On 07/07/26 at 01:40 PM, Administrative Nurse D verified staff should not touch their hair or scrubs while assisting the residents with their meal service or while delivering plates of food to the table. Administrative Nurse D stated she would hold an in-service immediately regarding proper hand hygiene and servicing of meals. The facility's Serving Basic policy, undated, documented staff would ensure safe serving practices to prevent contamination, and all team members would follow safe serving practices. The policy documented staff would ensure clean hands and utensils are used during dining service, and staff would not touch the food contact surface, handle by the edges, handles, or bottom or middle of the service ware.

Based on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)3's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications. Findings include: - R3's Electronic Health Record (EHR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, irrational fear) and hypertension (HTN-elevated blood pressure). R3's Significant Change Minimum Data Set (MDS) dated [DATE], recorded R3 had intact cognition. The MDS recorded that she required staff assistance with bed mobility and transfers. The MDS documented R3 received an antianxiety medication during the observation period. R3's Activities of Daily Living Care Plan, dated 06/26/2026, recorded R3 required assistance with activities of daily living (ADL) care. R's Psychotropic Drug Use Care Plan dated 06/26/26, dated 06/26/26, documented the resident received psychotropic medication with the potential for drug related complications related to pain and anxiety. The care plan documented R3 received Xanax (antianxiety medication) daily but lacked that she received a PRN dose, and the care plan lacked mention that R3 received lorazepam (antianxiety medication) as needed for anxiety. The care plan documented a pharmacy consultation would review R3's medications monthly. R3's Physician's Order, dated 06/15/2026, directed the staff to administer lorazepam 1.0 milliliters (ml) every eight hours as needed for anxiety PRN. The order lacked a stop date. R3's Physician's Order, dated 05/05/2026, directed staff to administer Xanax 0.25 milligrams (mg) every six hours as needed for anxiety PRN. The order lacked a stop date. R3's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam and the PRN Xanax. On 07/07/2026 at 08:00 AM, R3 sat up in her bed, and Certified Medication Aide (CMA) R administered the resident's morning medication, which included a scheduled Xanax. On 07/07/2026 at 01:30 PM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 06/15/2026 and received a Xanax PRN, with a physician order date of 05/05/2026. Administrative Nurse D verified the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rational. The Psychoactive Psychopharmacological Medications, policy dated 04/15/2025, documented psychotropic medications would be used only when a practitioner determines that the medication is appropriate to treat a resident's specific diagnosed and documented condition and the medication(s) are beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Psychoactive medications would be monitored by an interdisciplinary team (IDT) through the care planning process. Benefits and side effects of these medications would be discussed with the Primary Care Provider (PCP), so drug selection and dosages are adjusted as necessary to provide the best therapeutic effect for residents. Individualized behavioral interventions would also be addressed through the care planning process and documented on the electronic health record. The policy documented psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and subject to the limitations as noted: PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. PRN orders for antipsychotic medications only shall be limited to 14 days with no exception. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. The policy documented a drug regimen review would be conducted and documented monthly by a licensed nurse, pharmacist, or PCP. Drug irregularities, discrepancies, or non-compliance with regulatory guidelines is brought to the attention of the director of nursing, medical director, and attending PCP.

Based on observation, interview, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)3's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medications. Findings include:- R3's Electronic Health Record (EHR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, irrational fear) and hypertension (HTN-elevated blood pressure). R3's Significant Change Minimum Data Set (MDS) dated [DATE], recorded R3 had intact cognition. The MDS recorded that she required staff assistance with bed mobility and transfers. The MDS documented R3 received an antianxiety medication during the observation period. R3's Activities of Daily Living Care Plan, dated 06/26/2026, recorded R3 required assistance with activities of daily living (ADL) care. R's Psychotropic Drug Use Care Plan dated 06/26/2026, documented the resident received psychotropic medication with the potential for drug related complications related to pain and anxiety. The care plan documented R3 received Xanax (antianxiety medication) daily but lacked that she received a PRN dose, and the care plan lacked mention that R3 received lorazepam (antianxiety medication) as needed for anxiety. The care plan documented a pharmacy consultation would review R3's medications monthly. R3's Physician's Order, dated 06/15/2026, directed the staff to administer lorazepam 1.0 milliliters (ml) every eight hours as needed for anxiety PRN. The order lacked a stop date. R3's Physician's Order, dated 05/05/2026, directed staff to administer Xanax 0.25 milligrams (mg) every six hours as needed for anxiety PRN. The order lacked a stop date. R3's EMR lacked evidence of a specified duration, which included a physician's rationale for the extended use of the PRN lorazepam and the PRN Xanax. The Consultant Pharmacist monthly review for R3 completed on 05/05/2026, 06/02/2026, and 07/02/2026 lacked evidence that the CP identified the PRN lorazepam with no stop date, or the PRN Xanax with no stop date. On 07/07/2026 at 08:00 AM, R3 sat up in her bed, and Certified Medication Aide (CMA) R administered the resident's morning medication, which included a scheduled Xanax. On 07/07/2026 at 01:30 PM, Administrative Nurse D verified the resident received lorazepam PRN, with a physician order date of 06/15/2026, and received a Xanax PRN, with a physician order date of 05/05/2026. Administrative Nurse D verified the facility failed to obtain the 14-day stop date or a reason for the continued use with the appropriate rational. Administrative Nurse D verified the Consultant Pharmacist had sent monthly reviews to the facility and lacked a recommendation for the 14 days stop date or rational for continued use of the medication. The Psychoactive Psychopharmacological Medications, policy dated 04/15/2025, documented psychotropic medications would be used only when a practitioner determines that the medication is appropriate to treat a resident's specific diagnosed and documented condition and the medication(s) are beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication. Psychoactive medications would be monitored by an interdisciplinary team (IDT) through the care planning process. Benefits and side effects of these medications would be discussed with the Primary Care Provider (PCP), so drug selection and dosages are adjusted as necessary to provide the best therapeutic effect for residents. Individualized behavioral interventions would also be addressed through the care planning process and documented on the electronic health record. The policy documented psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and subject to the limitations as noted: PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. PRN orders for antipsychotic medications only shall be limited to 14 days with no exception. If the attending physician or prescribing practitioner believes it is appropriate to write a new order for the PRN antipsychotic, they must first evaluate the resident to determine if the new order for the PRN antipsychotic is appropriate. The Drug Regimen Review, policy, dated 02/03/25, documented the resident's medication regimen would be reviewed monthly and as needed by a licensed pharmacist. A Drug Regimen Review (DRR) is completed at admission by clinical staff. DRR is a thorough evaluation of resident's medication in order to improve outcome and minimize adverse outcomes or risks. A DRR would be conducted by the Pharmacist on day of admission, monthly, and as needed. A DRR would include medication reconciliation, medication review of all current medications, and the medications would be reviewed to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. The drug regimen would identify limitations of PRN prescriptions of psychotropic drugs, including anti-psychotic drugs for longer than 14 days.

Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to store Resident (R)21 and R3's oxygen tubing and nasal cannula in a sanitary manner. Findings included:1. On 07/07/2026 at 03:02 PM, observation revealed R21's unbagged oxygen tubing and nasal cannula coiled up and placed on the back of her wheelchair, located in the hall by her room.On 07/07/2026 at 03:03 PM, Licensed Nurse (LN) G verified the above observation and stated staff was to place R21's oxygen tubing and nasal cannula in a plastic bag when not in use. 2. On 07/08/2026 at 09:35 AM, observation revealed R3's uncovered oxygen tubing coiled up and placed on the top of the resident's wheelchair back. On 07/08/2026 at 09:39 AM, Administrative Nurse D verified R2's uncovered oxygen tubing on R2's wheelchair back with the cannula and tubing touching the wheelchair. Administrative Nurse D stated she would expect staff to store the residents' oxygen tubing and nasal cannula in a plastic bag when not in use. The facility's Oxygen Therapy Policy, revised 02/03/2025, documented when the oxygen device is not in use, store in a plastic or other bag to keep the tubing and device off the floor. Label bag with resident name, date, time, and staff initial.

The facility had a census of 29 residents. Based on observation, interview, and record review, the facility failed to submit complete and submit accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal year (FY) Quarter 3 2023 (April 1 - June 30) indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on six dates. A review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 08/12/24 at 09:52 AM observation revealed a registered nurse on duty in the facility. On 08/12/24 at 03:22 PM Administrative Staff A verified the facility did not send in the correct data to CMS for payroll-based data and stated the facility had new staff and was unaware the information was incorrect. The facility's undated, PBJ Reporting Procedure Policy, documented PBJ hours must be reported to CMS on a minimum of a quarterly basis, although it is highly recommended the hours be loaded and /or entered on a monthly basis. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 29 residents. The sample included 12 residents, with three reviewed for skin conditions not pressure-related. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent and treat skin tears and bruises for Resident (R) 19, who received skin tears and bruises during combative outbursts. This placed R19 at risk for further skin injury and pain due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion with other behavioral disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R19 had moderately impaired decision-making skills. R19 was dependent on staff for toileting, dressing, and personal hygiene; she required substantial assistance with transfers and bathing. R19 required partial assistance with mobility. The MDS documented R19 had rejection of care, physical and verbal behaviors for four to six days, and other behaviors for one to three days of the observation period. R19 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) and hallucinations (sensing things while awake that appear to be real, but the mind created). R19's Care Plan, dated 07/26/24, directed staff to complete a skin inspection with all cares and weekly bathing, observe for redness, open areas, scratches, cuts, and bruises, and report changes to the nurse. The care plan lacked direction to staff on the prevention of skin tears and bruises related to resistance or combativeness. The Nurse's Note, dated 05/23/24 at 12:53 AM, documented R19 had multiple bruises to her bilateral arms. Her left upper arm bruise measured 3.5 centimeters (cm) x 6 cm, a left upper forearm bruise was 4 cm x 7 cm, a left wrist bruise measured 1.5 cm x 3 cm, a left elbow bruise was 2 cm x 1.5 cm, the back of her right hand had a bruise that was 8 cm x 8 cm, and her right upper forearm had a bruise 6 cm x 6 cm. The note documented all the bruises were purple and documented R19 was combative with staff during care and hit the south wall next to her bed. The Nurse's Note, dated 05/26/24 at 05:00 PM, documented R19 was combative with staff during care. She hit, kicked, screamed, and cried. During care, R19 received a skin tear to her right forearm which measured 2.5 cm x 2.5 cm. The note documented staff cleansed the area and Kerofoam (non-adherent sterile dressing) was applied. The Nurse's Note, dated 06/05/24 at 05:44 AM, documented at 04:30 AM staff assisted R19 to the bathroom. The resident became combative, and staff noted R19 had blood on her right wrist. The edges of a skin tear were approximated and a foam dressing was applied. The Nurse's Note, dated 06/21/24 at 08:45 PM, documented R19 became combative with staff. She hit, bit, and pinched staff. The note further documented staff found a skin tear on R19's right forearm which measured 0.5 cm x 1.5 cm. The area was cleansed and an Aquacel (a soft, sterile dressing) was applied. The Nurse's Note, dated 07/23/23 at 09:54 PM, documented that during bedtime care R19 became combative and hit the back of her right forearm on the wall in the bathroom which caused a skin tear that measured 2 cm. The area was cleansed and two Band-Aids were applied. The Nurse's Note, dated 08/12/24 at 01:10 AM, documented R19 was extremely aggressive, screamed, and fought staff. The note documented that as staff attempted to provide personal care to R19, she tried to bite staff, and she took her doll and hit the wall. She hit her knuckles on the wall. The note further documented R19 continually had bruising on her arms and hands due to her hitting the wall. The Nurse's Note, dated 8/12/14 at 01:58 PM, documented R19 was very upset while three staff took her to the restroom. Staff tried to reassess R19 after she calmed down a little, but she was still upset. The note further documented two staff grabbed her arms and another staff member grabbed her hands so they could get R19's incontinence brief on and off. R19 was placed back into her wheelchair and was taken to a table to eat. On 08/14/24 at 12:00 PM, observation revealed a foam dressing on R19's left forearm. On 08/12/24 at 04:15 PM, Administrative Nurse D stated the care plan should reflect R19's skin integrity and provide direction to staff on how to prevent skin tears and bruises on R19 when she was combative. The facility's Care Plan policy, dated 07/28/22, documented the person-centered plan of care was developed for each resident by the interdisciplinary team through assessments within the established timeframes according to state and federal regulations. The person-centered care plan would be reviewed and revised quarterly if needed, annually, and when significant changes occur. The facility failed to revise the care plan with interventions to prevent and treat skin tears and bruises for R19. This placed R19 at risk for further skin injury and pain due to uncommunicated care needs.

The facility had a census of 29 residents. The sample included 12 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 remained free from preventable accidents when staff failed to ensure R1 was positioned on the bed properly before placing her legs in bed, causing her to roll out of bed. This placed the resident at risk for injury related to preventable accidents. Findings Included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, pain, a history of falls, abnormalities of gait and mobility, and hypertension (high blood pressure). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had significantly impaired cognition and required substantial assistance with toileting, dressing, mobility, and transfers. R1 had no functional impairment and had no falls. The Fall Risk Assessment. dated 05/03/24, documented R1 was a high risk for falls. R1's Care Plan, dated 05/22/24 and initiated on 10/20/22, directed staff to ensure her bed was in the position that was easiest for her to access or exit. The update, dated 06/20/23, documented R1 needed a safe environment with even floors free from spills and/or clutter; adequate glare-free light, a working and reachable call light, the bed in a low position at night, handrails on the walls, and her personal items within reach. The Nurse's Note, dated 08/07/24 at 07:48 PM, documented staff walked R1 to her bed and told her to lie down. The note recorded that as the Certified Nurse Aide (CNA) grabbed R1's legs to put them into the bed, R1 slipped off the bed and was between the bed and the arm of the recliner. The note documented three staff assisted R1 up and back into bed. On 08/13/24 at 11:30 AM, observation revealed CNA N and CNA O placed a gait belt around R1's wait, placed her walker in front of her, had her stand up, and walked with her to the bathroom. On 08/12/24 at 04:15 PM, Licensed Nurse (LN) G stated R1 had not had incidents or falls that she was aware of. LN G stated that R1 was a two-person transfer. On 08/13/24 at 08:30 AM, Administrative Nurse D stated she was unaware of the incident with R1 and said it should be reported to administration to complete an investigation and educate staff. On 08/13/24 at 03:45 PM, CNA M stated she was unaware of any falls or the incidents of R1 slipping off the bed. CNA M stated R1 was a two-person transfer and staff were to make sure R1's bed was in a low position at night. The facility's Lifting and Transferring Resident policy, dated 10/11/21, documented that staff are accountable for utilizing proper body mechanics, lifting techniques, and resident safety. The facility failed to ensure R1 remained free from preventable accidents. This placed the resident at risk for injury related to accidents.

The facility had a census of 29 residents. The sample included 12 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to follow the plan of care and provide appropriate behavioral health care for Resident (R) 19, who had behaviors and was combative with care. This deficient practice resulted in skin tears and bruises and placed R19 at risk for impaired quality of life. Findings included: - The Electronic Medical Record (EMR) for R19 recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion with other behavioral disturbances, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R19 had moderately impaired decision-making skills. R19 was dependent on staff for toileting, dressing, and personal hygiene; she required substantial assistance with transfers and bathing. R19 required partial assistance with mobility. The MDS documented R19 had rejection of care, physical and verbal behaviors for four to six days, and other behaviors for one to three days of the observation period. R19 had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) and hallucinations (sensing things while awake that appear to be real, but the mind created). R19's Care Plan, dated 07/11/24 and initiated on 02/03/23, documented that if R19 became agitated or combative, ensure she was safe, leave her alone and reapproach her later. The plan directed staff to offer alternative ways to safely relieve her anger such as sitting and talking with her or walking away and giving her space so that she could calm down. The care plan documented R19 had a history of hitting people and disrobing in public and directed staff to monitor her behaviors. The care plan directed staff to be aware of symptoms or triggers, confining situations, and pressure to make decisions or choices. The update, dated 03/20/23, directed staff to offer R19 activities, her baby doll, or stuffed animals when she had exit-seeking behaviors. The care plan lacked direction to staff on the prevention of skin tears and bruises related to resistance or combativeness. The Nurse's Note, dated 05/23/24 at 12:53 AM, documented R19 had multiple bruises to her bilateral arms. Her left upper arm bruise measured 3.5 centimeters (cm) x 6 cm, a left upper forearm bruise was 4 cm x 7 cm, a left wrist bruise measured 1.5 cm x 3 cm, a left elbow bruise was 2 cm x 1.5 cm, the back of her right hand had a bruise that was 8 cm x 8 cm, and her right upper forearm had a bruise 6 cm x 6 cm. The note documented all the bruises were purple and documented R19 was combative with staff during care and hit the south wall next to her bed. The Nurse's Note, dated 05/26/24 at 05:00 PM, documented R19 was combative with staff during care. She hit, kicked, screamed, and cried. During care, R19 received a skin tear to her right forearm which measured 2.5 cm x 2.5 cm. The note documented staff cleansed the area and Kerofoam (non-adherent sterile dressing) was applied. The Nurse's Note, dated 06/05/24 at 05:44 AM, documented at 04:30 AM staff assisted R19 to the bathroom. The resident became combative, and staff noted R19 had blood on her right wrist. The edges of a skin tear were approximated and a foam dressing was applied. The Nurse's Note, dated 06/21/24 at 08:45 PM, documented R19 became combative with staff. She hit, bit, and pinched staff. The note further documented staff found a skin tear on hR19's right forearm which measured 0.5 cm x 1.5 cm. The area was cleansed and an Aquacel (a soft, sterile dressing) was applied. The Nurse's Note, dated 07/23/23 at 09:54 PM, documented that during bedtime care R19 became combative and hit the back of her right forearm on the wall in the bathroom which caused a skin tear that measured 2 cm. The area was cleansed and two Band-Aids were applied. The Nurse's Note, dated 08/12/24 at 01:10 AM, documented R19 was extremely aggressive, screamed, and fought staff. The note documented that as staff attempted to provide personal care to R19, she tried to bite staff, and she took her doll and hit the wall. She hit her knuckles on the wall. The note further documented R19 continually had bruising on her arms and hands due to her hitting the wall. The Nurse's Note, dated 8/12/14 at 01:58 PM, documented R19 was very upset while three staff took her to the restroom. Staff tried to reassess R19 after she calmed down a little, but she was still upset. The note further documented two staff grabbed her arms and another staff member grabbed her hands so they could get R19's incontinence brief on and off. R19 was placed back into her wheelchair and was taken to a table to eat. On 08/12/24 at 01:40 PM, observation revealed R19 cried in the dining room as staff took her into the bathroom. R19 stated she did not want to go into the bathroom and staff continued to tell her they needed to take her. Continued observation revealed R19 yelled in the bathroom and multiple staff went in and out of the bathroom during the encounter. On 08/13/24 at 9:45 PM, Licensed Nurse (LN) H stated R19 had aggressive behaviors. LN H said when R19 was combative, staff were directed to leave her alone and reapproach her later. On 08/13/24 at 03:45 PM, Certified Nurse Aide (CNA) M stated R19 had a lot of behaviors and could get combative. CNA M further stated that during her shift, staff tried to have three staff present in R19's room to provide care so that they could hurry up and get her care done. On 08/12/24 at 04:15 PM, Administrative Nurse D stated staff should follow the care plan and when R19 was combative, staff should make sure she was safe and reapproach her later. Administrative Nurse D further stated three staff in the room would be overwhelming to R19 and said education would be provided to staff on how to approach R19. The facility's Behavioral Health Services policy, dated 10/27/22, documented that staff providing behavioral health services are an integral part of the person-centered environment involving an interdisciplinary approach to care with qualified staff that demonstrates the competencies and skills necessary to provide mental health and behavioral health services, non-pharmacological interventions would be implemented for residents with identified behavioral health training consistent with provisions of the policy and procedure at the time of employment, prior to caring for any resident with identified behavioral health issues. The facility failed to follow the plan of care for R19 during combative outbursts and resistance to care. This resulted in skin tears and bruises, and further placed R19 at risk for impaired quality of life.

The facility had a census of 29 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one sampled resident, Resident (R) 19. This placed the resident at risk for fecal impaction and physical decline. Findings included: - The Electronic Medical Record EMR for R19 recorded diagnoses of dementia (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), diabetes mellitus (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), pain, and constipation (difficulty in emptying the bowels). The Significant Change Minimum Data Set, dated dated [DATE], documented R19 had moderately impaired decision-making skills. R19 was dependent on staff for personal hygiene, toileting, and dressing; R19 required substantial assistance with transfers. The MDS documented R19 was occasionally incontinent of bowel. R19'sCare Plan, dated 07/11/24 and initiated on 07/26/23, directed staff to follow the facility's bowel protocol for bowel management and administer medications for constipation prevention as ordered. The care plan directed staff to monitor for changes in her mental status, new-onset confusion, agitation, abdominal distension, vomiting, small loose or hard stools, bowel sounds, and fecal impaction. R19's Bowel and Bladder Screen, dated 03/18/24, documented R19 was always incontinent of bowel and had routine bowel elimination patterns. The Physician's Order, dated 01/03/24, directed staff to administer magnesium hydroxide (a laxative), 400 milligrams (mg)/5 milliliters (ml), by mouth, every eight hours, as needed, for constipation. The Physician's Order, dated 01/11/24, directed staff to administer MiraLax (a laxative), 17 grams (gm), by mouth, as needed, daily, for constipation. R19's Bowel Monitoring Record, dated July 2024, documented R19 did not have a bowel movement for the following days: 07/06/24-07/11/24 (six consecutive days) The Medication Administration Record (MAR). dated July 2024, lacked documentation the staff provided the physician-ordered interventions during the lack of bowel elimination on the above dates. On 08/12/24 at 03:45 PM, observation revealed R19 wheeled into her bathroom. She pulled on the waistband of her pants and stated she needed to go to the bathroom. On 08/12/24 at 03:45 PM, Licensed Nurse (LN) G stated R19 required assistance from staff with toileting. LN G said when R19 had a bowel movement, the staff would document it, and a report was generated for residents who had not had a bowel movement. On 08/13/24 at 03:50 PM, Certified Nurse Aide (CNA) M stated she documented if the resident had a bowel movement. On 08/14/24 at 09:15 AM, Administrative Nurse D verified staff had not provided interventions to R19 when she had not had a bowel movement for six days. Administrative Nurse D stated after three days, staff should follow the facility bowel protocol. The facility's Bowel Elimination policy, dated 04/03/19, documented the facility's established guidelines for monitoring individual bowel function to promote regularity of bowel functions and avoid possible complications such as constipation, obstruction, or other complications by utilizing a multidisciplinary approach. If a resident did not have a bowel movement in three days, or nine consecutive shifts or has positive signs and symptoms of constipation, the LN would perform an evaluation to include auscultation and palpation, the physician would be notified of bowel status and assessment findings including medication utilization. The facility failed to monitor and provide interventions for bowel management for R19. This placed the resident at risk for fecal impaction and physical decline.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required when staff failed to place an open date on Resident (R) 17's Novolog (rapid-acting medication that works by lowering levels of glucose in the blood) flex pen (a device used to inject insulin). This placed the resident at risk of receiving an expired and ineffective dose of insulin. Findings included: - On [DATE] at 08:15 AM, observation of the treatment cart revealed R17's Novolog flex pen without an open date or discard date. On [DATE] at 08:15 AM, Licensed Nurse (LN) I verified the above finding. LN I stated the insulin should be labeled with an open date. LN I discarded the insulin pen in the Sharps container on the treatment cart. On [DATE] at 11:30 AM, Administrative Nurse D stated she expected staff to label open insulin pens with the date opened whenever staff get a new pen for R17. Medlineplus.gov documented all unrefrigerated, open pens of Novolog can be used within 28 days, but after that time they must be discarded. The facility's Vials and Ampules or Injectable Meds Policy, revised [DATE], documented the date opened should be recorded on multidose vials (on the vial label or an accessory label affixed for that purpose). The facility failed to place open and/or discard dates on R17's Novolog flex pen. This placed the resident at risk of receiving an expired or ineffective dose of insulin.

The facility had a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 28 residents who resided in the facility and received meals from the facility kitchen, which placed the resident at risk for food borne illness. Finding included: -On 03/02/23 at 12:00 PM, observation revealed foods prepared in the kitchen located in the basement of the facility, loaded into a heat preserving cart and taken to the elevator up to the long- term care unit of the facility. The hot food items then transferred to the steam table in the kitchenette. Dietary Staff (DS) CC then observed checking the food temperatures with an electronic thermometer. The Fahrenheit (F.) temperature of the following foods were as followed: Rice at 174 F. Broccoli 168 F. Mashed Potatoes 177 F. Asparagus 165 F. Shredded/Deboned Chicken 125 F. Ground Chicken 123 F. Pureed Chicken 112 F. Pureed Broccoli 122 F. DS CC then placed the serving utensils in the food items to begin the plating process. As DS CC began the first plate, this surveyor inquired if DS CC knew the holding temperature of food prior to being served. DS CC stated she did not know what the holding/serving temperature and stated the food was always hot from the kitchen. Another Dietary staff member then in the kitchenette stated the food would have to return to the steamer in the kitchen to be heated to the correct holding temperature. Dietary staff removed and covered for transport back to kitchen, all the chicken and broccoli from the steam table, placed in back into the heat preserving cart and back to the kitchen for reheating. The serving utensils were placed on a plate and remained on the steam table cart. On 03/02/23 at 12:25 PM the heat preserving cart was returned to the kitchenette and foods placed into the steam table, the temperatures were taken with the results of: Shredded/Deboned Chicken 150 F. Ground Chicken 166 F. Pureed Chicken 140 F. Pureed Broccoli 140 F. The facility's Reheating of Food on the Nursing Unit Sanitation and Infection Control policy, dated 11/2017, documented when food is transported to an auxiliary serving site or nursing unit, the temperatures need to be taken and recorded prior to meal distribution. Hot food must be held at or above 135 degrees. If hot food temperature falls below 135, the hot food must be reheated two hours or less. The facility failed to ensure the holding temperature of transported food items which placed the residents at risk for food borne illness.

The facility had a census of 29 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two of the 13 residents which had falls. The deficient practice placed the residents at risk of inaccurate care needs for Resident (R) 3 and R19. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of an interior trochanter fracture (top portion into hip socket) of right femur (thigh bone), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), pain, repeated falls and insomnia (inability to sleep). The EMR Interdisciplinary Notes recorded R3 fell on [DATE], 08/16/22, 08/22/22 and 08/23/22. R3's Nursing Home Medicare A Skilled Payment End (NPE), dated 09/27/22, lacked documentation of falls during since the prior assessment. The EMR Interdisciplinary Notes recorded R3 fell on [DATE], 10/03/22, 10/04/22, 10/07/22, 10/13/22, and 10/23/22. R3's Significant Change Minimum Data Set (MDS), dated [DATE], lacked documentation of falls since prior assessment. On 03/07/23 at 01:35 PM, Administrative Nurse E verified R3 had numerous falls and verified the falls had not been coded on the MDS. Administrative Nurse E stated she lacked coding the falls and would submit a correction for the fall section of the MDS. The facility's MDS Data Accuracy policy, dated 06/10/19, documented it was the responsibility of those who complete sections of the MDS to ensure date entered accurately reflect the resident's status and is coded accordingly to the Resident Assessment Instrument (RAI) manual guidelines. If MDS documentation inaccuracies or disparities are ascertained, the process of editing the documentation source, in addition to correction MDS will be instated. Validating MDS data for accuracy, prevents any issue with supportive documentation not matching the MDS and can help protect against any documentation issues arising in survey or audits. The facility failed to correctly code the MDS, placing R3 at risk for incomplete assessment and inaccurate care needs related to falls. 32360 - R19's Electronic Medical Record (EMR) recorded diagnoses of hypertension (high blood pressure), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should) and back pain. The EMR Interdisciplinary Notes recorded R19 had fallen on 06/11/22. R19's Quarterly Minimum Data Set (MDS), dated [DATE], lacked documentation of falls since the prior assessment. The EMR Interdisciplinary Notes recorded R19 fell on [DATE] and 01/23/23. R19's Quarterly MDS, dated [DATE], lacked documentation of falls since the prior assessment. On 03/07/23 at 01:27 PM, Administrative Nurse E verified R19 had numerous falls and verified the falls had not been coded on the MDS. Administrative Nurse E stated she lacked coding the falls and would submit a correction for the fall section on the MDS. The facility's MDS Data Accuracy policy, dated 06/10/19, documented it was the responsibility of those who complete sections of the MDS to ensure data entered accurately reflect the resident's status and is coded accordingly to the Resident Assessment Instrument (RAI) manual guidelines. If MDS documentation inaccuracies or disparities are ascertained, the process of editing the documentation source, in addition to correcting the MDS, will be initiated. Validating MDS data for accuracy, prevents any issue with supportive documentation not matching the MDS and can help protect against any documentation issues arising in survey or audits. The facility failed to correctly code the MDS, placing R19 at risk for incomplete assessment and inaccurate care needs related to falls.

The facility had a census of 29 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to revise one care plan for antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for one sampled resident, Resident (R) 9. This placed the resident at risk for inaccurate side effect monitoring. Findings included: - The Electronic Medical Record (EMR) documented R9 had diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, or confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS further documented R9 had physical and verbal behaviors towards others four to six days, other behaviors one to three days, feeling bad about herself two to six days, and R9 received antidepressant) medications during the look back period. The Care Plan, dated 02/23/23, originated on 04/05/21, documented R9 received Zoloft, (an antidepressant medication), and directed staff to monitor for side effects such as somnolence (drowsiness), insomnia (persistent problems falling and staying asleep), headache, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), constipation (difficult bowel movements), and diarrhea (loose, watery stools). The Physician Order, dated 11/04/22, originally ordered 03/14/21, directed staff to administer Zoloft, 100 milligrams (mg), by mouth, daily, for depression. The Zoloft medication was discontinued 01/09/23. The Physician Order, dated 11/04/22, originally ordered 08/25/22, directed staff to administer Zoloft, 50 milligrams (mg), by mouth, daily, for depression. The Zoloft medication was discontinued 01/09/23. The Physician Order, dated 01/09/23, directed staff to administer desvenlafaxine succinate (an antidepressant that also treats anxiety), 25 mg, by mouth daily. On 03/02/23 at 08:09 AM, observation revealed R9 was verbally aggressive with staff stating they were incompetent and should not be working. On 03/07/23 at 10:27 AM, Administrative Nurse E stated that usually social service would update the care plans regarding behaviors and medications and stated there was not a social service person working at this time so she would revise the care plan and remove the inaccurate medication and add in the new medication and side effects. The facility Care Plan policy, dated 07/28/22, documented a person-centered plan of care would be reviewed and revised quarterly if needed, annually and when a significant change occurred. The team would utilize the results of the assessments to develop, review and revise the resident's comprehensive plan of care. The facility failed to revise R9's care plan with the appropriate antidepressant medication. This placed the resident at risk for inaccurate side effect monitoring.

The facility had a census of 29 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide medically- related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one sampled resident, Resident (R) 9, who had behaviors. This placed the resident at risk for further decline of her emotional and mental well-being. Findings included: - The Electronic Medical Record (EMR) documented R9 had diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, or confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had intact cognition and required extensive assistance of two staff for bed mobility, transfer, dressing, toileting, and personal hygiene. The MDS further documented R9 had physical and verbal behaviors towards others four to six days, other behaviors one to three days, felt bad about herself two to six days, and received antidepressant (medication used to treat mood disorders and relieve symptoms of depression) medications. The Care Plan, dated 02/23/23, documented R9 could be short tempered and easily angered, had socially inappropriate behavior, offensive/defensive behaviors as evidenced by verbal outburst, demeaning comments when staff attemptedt to help but did not meet R9's standards. The care plan further documented staff should assess R9's mood and behavior when approaching her and request a second staff member. R9's behavior would be managed to ensure optimal quality of life over the next 90 days. R9 was purposeful, threatening to others, and had physical behaviors of hitting and pinching others; R9 participated in psychological services. The Nurse's Note, dated 11/30/22 at 07:33 PM, documented R9 was verbally and physically abusive and scratched a Certified Nurse Aide (CNA) in two places and grabbed the CNA by the neck of her shirt. The Nurse's Note, dated 12/14/22 at 07:30 PM, documented R9 tried to hit a CNA three times and pushed the mechanical lift into the CNA's leg. The Nurse's Note, dated 12/15/23 at 02:52 AM, documented R9 called a CNA a demeaning offensive name related to the CNA's weight. The note further documented staff placed R9's phone on the bedside table from the bed and R9 accused her of stealing her phone. The Nurse's Note, dated 12/15/22 at 03:26 AM, documented R9 stated staff were too stupid to do things right after staff cleaned R9's floor and picked up extra cleansing wipes the resident had pulled out of the package and threw on the floor. The note further documented R9 became upset when staff threw the wipes away because she felt they were still clean. The Social Service Note, dated 12/15/22 at 04:04 PM, documented the Social Services Designee (SSD) met with R9 to discuss various topics ranging from Quality of Care to how R9 feels no one visits her. The note further documented R9 continued to have long and short-term memory challenges as demonstrated when R9 was asked what the date was and what major holiday was next week. R9 stated that she had a birthday later in the month and she would be [AGE] years old. The note documented the SSD did not correct R9 as her birthday was in February and she would be [AGE] years old. The Nurse's Note, dated 12/18/22 at 01:01 PM, documented two staff reported that R9 called them names, screamed at them, and hit one of them in the eye. The note further documented staff left R9 in a safe place and left the room. The Nurse's Note, dated 12/18/22 at 08:19 PM, documented R9 scratched a CNA on the arm and called the CNA names. The note further documented R9 wiped herself after urinating, held out the cleansing wipe and stated, do you want to sniff it? The note documented R9 continued to be verbally abusive and as the CNA started to lotion R9's legs, she started kicking at him. The Nurse's Note, dated 12/25/22 at 10:21 PM, documented R9 was verbally abusive to staff and stated, verbalized offensive religious connotations and used profanity, and continued to call staff stupid and dumb. The Nurse's Note, dated 12/28/22 at 10:38 PM, documented R9 scratched a CNA on the arm when the CNA tried to turn off R9's call light. the note further documented R9 refused to let staff turn it off and tried to kick the CNA in the face. The Nurse's Note, dated 01/10/23 at 10:00 PM, documented during bedtime cares R9 hit, kicked, and tried to pull a CNA's hair. The note further documented when R9 asked the CNA to get something out of her walker, when the CNA reach to get the item, she accused the CNA of stealing something. When the CNA asked R9 what she wanted, she stated I don't want anything. Staff left R9 in bed and left the room. The note further documented R9 called down to the nurse's station and stated staff left her room and did not put her head up along with a list of cares staff did not do. The nurse stated, cares were not completed due to her hitting and kicking, and the CNA's went back to R9's room to finish her cares. The Nurse's Note, dated 01/31/23 at 01:15 AM, documented a resident had wandered into R9's room and R9 started throwing stuff at the resident to get her to leave the room. The note further documented staff arrived at the room quickly and escorted the confused resident out of the room and was not hit by the flying debris. The note further documented R9 was encouraged to call out for staff or use her call light instead of throwing things. R9 stated she understood and will see the next time the resident wandered into her room. The Nurse's Note, dated 02/01/23 at 05:48 AM, documented R9s stated the CNA did not know what she was doing and should go back to school. The note further documented R9 told the CNA, you should die, I do not want you in here anymore. The Nurse's Note, dated 02/13/23 at 04:37 AM, documented R9 call staff names and told them how worthless they were and should not be working with older people due to their incompetency. The Nurse's Note, dated 02/27/23 at 05:41 AM, documented R9 had called staff names all shift and had swung her walker at a staff member. The note further documented staff stopped the walker from hitting him when he grabbed the wheels of the walker and when R9 told him to let go, he did. The Nurse's Note, dated 03/02/23 at 08:36 AM, documented R9 hit two different staff on their arms four times, called them names and belittled them. On 03/01/23 at 03:34 PM, R9 stated her husband had passed away, they would have been married [AGE] years and she really missed him. R9 stated this several times during the conversation as well talking about her grandchildren and great grandchildren. R9 stated she had two sisters who were still alive but had lost both brothers. During the conversation, R9 kept bringing up her husband and how sad she was that he was no longer with her. On 03/02/23 at 08:09 AM, observation revealed R9 was verbally aggressive with staff stating they were incompetent and should not be working. R9 stated the Certified Medication (CMA) should be fired and would not take her medication until R9 was finished putting on her makeup. On 03/02/023 at 11:01 AM, CNA N stated R9 had hit, slapped, and even thrown her walker at her during cares. CNA N further stated R9 had found out she was pregnant and had made derogatory remarks about the baby and how she pitied the baby for having CNA N as her mother. CNA N stated when R9 got nasty, she got the nurse to assist and stated R9 would get more abusive if you did not gossip with her. On 03/02/23 at 05:00 PM, Administrative Staff A stated the facility had a social worker that was not in the building but would come to the facility weekly and as needed. Administrative Staff A stated she was unsure if the social worker had visited with R9. On 03/06/23 at 02:12 PM, CNA M stated when R9 got nasty, she goes to the nurse for assistance and stated she was unsure what would trigger the behaviors except R9 did not like the mechanical lift. On 03/07/23 at 08:15 AM, Licensed Nurse (LN) G stated R9 was verbally and physically abuse to staff and she would often go in to assist the CNA's. LN F further stated when she was assisting, R9 was not physically abusive but would continue to be verbally abusive. LN G stated R9 did have a mental health nurse that would visit with her, but was unsure how often. LN G stated the facility did not have a SSD or anyone providing social work services. On 03/07/23 at 12:35 PM, Administrative Nurse D stated there was not a social service person in the building, but they had a social worker that would come to the building weekly . Administrative Nurse D was unsure if R9 had been seen recently. Administrative Nurse D further stated, she visited with R9 weekly about behaviors but had not documented the visits or what had been discussed. Administrative Nurse D stated the facility had sent a referral to a behavior unit in September but at that time there was not a bed available and when there was a bed, R9 refused to go, so they along with the family opted for medication at this time. Administrative Nurse D stated a mental health nurse did visit with R9 on a regular basis. The facility Social Worker policy, dated October 13, 2021, documented the social services director was a qualified social worker or social service designee and was responsible for assistance in meeting the social and emotional needs of residents. The medically related social services are provided to maintain or improve resident's ability to maintain highest level of function, mental and psychosocial needs. The social service provided assistance with behavioral problems and provided corrective action for the resident's needs. The social service makes supportive visits to residents and performed needed services, communications with the family or friends, coordinates resources and services to meet resident needs. The facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one sampled resident, R9, who had behaviors. This placed the resident at risk for further decline of her emotional and mental well-being.

The facility had a census of 29 residents. The sample included 13 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate indication for use for one of six sampled residents, Resident (R) 28's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication, Seroquel. This placed the resident at risk for adverse side effects related to antipsychotic use. Findings included: - The Electronic Medical Record (EMR) for R28 documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], documented R28 had severely impaired cognition and required supervision of one staff for transfers, ambulation, eating ad limited assistance of one staff for bed mobility, dressing, and toileting. The assessment further documented R28 had inattention, disorganized thinking, physical and verbal behaviors, rejection of care , wandering, and did not receive any medications during the lookback period. R28's Care Plan, dated 02/03/23, documented R28 had a behavior problem and directed staff to monitor and document her behaviors. The update, dated 02/13/23, directed staff to administer Seroquel as ordered, monitor and report any side effects. The Physician Orders, dated 02/17/23, directed staff to administer Seroquel, 25 milligrams (mg) by mouth at bedtime for behaviors. On 03/02/23 at 11:32 AM, observation revealed R28 in the dining room participating in group exercises. On 03/06/23 at 05:00 PM, Administrative Nurse D verified behaviors was not an appropriate diagnosis for the Seroquel medication and stated R28 would be evaluated by the mental health nurse due to her dementia. The facility Psychoactive Psychopharmacological Medications policy, dated 07/05/22, documented psychotropic medications are given to treat specific conditions, diagnoses, and was documented in the clinical record. The facility failed to ensure an appropriate indication for the use of R28's Seroquel, placing the resident at risk for adverse side effects.

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to employ a full time certified dietary manager for the 21 residents who resided in the facility and received meals from the facility kitchen. Findings included: - On 09/01/21 at 10:10 AM, observation revealed Dietary Staff (DS) CC overseeing the preparation of the noon meal. On 08/30/21 at 08:45 AM, DS CC verified she was uncertified and was enrolled in the Nutrition and Food Service Professional training program. On 09/02/21 at 11:20 AM, Administrative Nurse D verified DS CC had no dietary manager certification and she was enrolled in the program. Upon request the facility failed to provide a policy regarding certified dietary manager. The facility failed to employ a full time Certified Dietary Manager for the 21 residents who resided in the facility and received meals from the facility kitchen, placing the residents at risk for receiving inadequate nutrition.

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview the facility staff failed to distribute and serve food in accordance with professional standards for food service safety for the 21 residents who received meals from the facility kitchenette and kitchen. Findings included: - On 08/30/21 at 08:45 AM, observation of the kitchen revealed two uncovered desert cups with soft serve vanilla ice cream, without a label or date. On 09/01/21 at 10:50 AM, observations revealed the following in the kitchen: the oven next to dietary manager's office, had black crusted material. the floor and base board along the wall, underneath the three sinks, had accumulated gray sticky substance approximately 4 inch (in) wide by 5 foot (ft) long. On 09/01/21 at 12:20 PM, observation revealed Dietary Staff (DS) BB with gloves on, touched the refrigerator door, the kitchenette counter, the steam table, then with the same contaminated gloves, took half a chicken salad sandwich from a zip lock bag and placed it on a resident's plate. On 09/01/21 at 12:38 PM, observation revealed under the prep area sink, two approximately 1/4 and 1/3 gallon plastic containers of chloride ACS freedom floor cleaner. On 08/30/21 at 08:45 AM, DS BB verified the two uncovered desert cups with soft serve ice cream without a label or date. DS BB removed and discarded the items and stated staff should cover, label and date food items placed in the refrigerator. On 09/01/21 at 10:50 AM, DS BB verified the oven by the dietary manager office and the base board and floor underneath the three sink needed cleaned and stated staff had not had time to clean them due to shortage of staff. On 09/01/21 at 01:03 PM, DS BB verified she used a contaminated glove to take the 1/2 chicken salad sandwich out of a zip lock bag and placed on a resident's plate. DS BB stated she should have used tongs. On 09/01/21 at 12:38 PM, DS CC verified the chemicals underneath the prep area sink and stated they should be stored away from serving and prep area. DS CC removed and placed them in a room with other chemicals. On 09/02/21 at 12:22 PM, DS CC stated she expected staff to cover, label, and date food items before placing them in the refrigerator. Upon request, the facility failed to provide a policy regarding hand hygiene while serving residents meals. The facility's undated Food Storage (Dry, Refrigerated and Frozen) policy instructed staff to never leave any food item uncovered and unlabeled in dry storage, refrigerator or freezer. The facility staff failed to distribute and serve food, in accordance with professional standards for food service safety, to the 21 residents who received their meals from the facility kitchenette and kitchen.

The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review and interview, during medication administration, staff failed to prepare a medication according to the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included: - On 09/01/21 at 09:02 AM, observation revealed, during medication administration, Certified Medication Aide (CMA) M crushed R10's [MEDICATION(S)] (medication used to treat lung diseases to prevent wheezing and shortness of breath) 400 milligram (mg) extended release (ER) and placed in a medication cup with other crushed medications. CMA M picked up the medication cup and started to leave the cart, the surveyor stopped CMA M and asked her if she should have crushed [MEDICATION(S)]. CMA M looked at the medication administration record (MAR) and stated it does document not to crush. CMA M took the medications and placed them in the sharps container in the medication room. CMA M stated the resident usually took her medications whole but today she had observed during breakfast meal the resident was not swallowing well. The September 2021 MAR instructed staff do not crush the [MEDICATION(S)] in the box in the left hand corner. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/01/21 at 09:41 AM, Pharmacist GG stated per telephone interview, [MEDICATION(S)] ER should not be crushed because instead of releasing the medication throughout the day, the medication was delivered all at once. On 09/02/21 at 11:20 AM, Administrative Nurse D stated special instructions for medications are listed in the bottom left hand corner in a box on the MAR and she would expect staff to follow the instructions. Administrative Nurse D stated she had educated CMA M on where to find the special instructions. Upon request the facility failed to provide a medication administration policy. The facility staff failed to administer [MEDICATION(S)] ER in the correct form to R10, placing the resident at risk for receiving inappropriate dosage of the medication which could cause shortness of breath.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to provide a safe, clean, comfortable environment for the 29 residents residing in the facility. Findings included: - On 6/20/19 at 8:20 AM, during the environmental tour revealed the following: Sunflower Hall: Resident #9's and #8's bottom of door with black scuff marks approximately 2 (ft) foot long by 5 inches wide. Spa room bottom of door with black scuff marks approximately 2 ft long by 2 ft wide. Utility room door with black scuff marks approximately 2 ft by 2 ft on bottom of door. Resident #5's carpet in doorway with a dark stain approximately 4 ft by 3 ft. Meadowlark Lane: Resident #23's and #16's, room carpet with dark colored stains approximately 4 ft by 3 ft. Resident #3's and #26's bottom of door with approximately 2 ft by 2 ft black scuff marks. Resident #6's bottom of door with 2 ft by 2 ft black scuff marks. Resident #24's room carpet with dark stains in middle of the room approximately 4 ft by 4 ft. A strong urine odor was observed 3 of the 4 days of the survey at the end of the Meadowlark Lane hall. Dining Room: Carpeting in middle of the room with approximately a 1 ft ripple. The 22 ft long silver metal strip across the center of the dining room floor, with numerous stains, dark stains and dried crusty particles on the carpet. 15 of the dining room chair with dried crusty substance on the seats and legs of the chairs. On 6/20/19 at 9:40 AM, Maintenance Staff U and Administration Staff A verified the above findings. The 7/2018 Safe and Homelike Environment policy states the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and Maintenance services will be provided as necessary to maintain a sanitary and orderly environment and are to minimize odors and clean areas appropriately. The facility failed to provide a safe, functional, sanitary environment, placing the 29 residents who reside in the facility at risk for not living in a home-like environment.

The facility had a census of 29 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to promote respect and dignity for 1 of 12 sampled residents. (#3) Findings included: - Resident #3's quarterly (MDS) Minimum Data Set assessment, dated 3/24/19, documented the resident had a (BIMS) Brief Interview for Mental Status Score of 3, indicating severe cognitive impairment. The assessment documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, personal hygiene, and extensive assistance of 1 staff for eating. The assessment further revealed the resident had a [MEDICAL CONDITION] of his/her right lower leg. The 9/5/18 (CAA) Care Area Assessment for (ADLs) Activities of Daily Living documented the resident did not always want to feed him/herself and required staff assistance. The 4/18/19 care plan documented the resident used a bedside table in the dining room to eat and at times would spit out his/her food. The care plan directed staff to leave the residents foot pedal on his/her wheelchair until the staff were ready to transfer the resident to remind him/her to stay seated. On 6/20/19 at 8:30 AM, observation revealed the resident's wheelchair wheels had dried food and the cushion on the elevated foot pedal had various dried stains and dried food particles on it. On 6/24/19 at 8:25 AM, observation revealed the resident's wheelchair cushion had crumbs and dried food stains on it, and the cushion on the elevated foot pedal had various dried stains and dried food particles on it. On 6/24/19 at 8:45 AM, Nurse Aide O verified the wheelchair, wheelchair cushion, and foot pedal cushion were dirty and had dried food particles. Nurse Aide O stated the night shift staff were responsible for cleaning the resident's wheelchair. On 6/24/19 at 9:50 AM, Administrative Nurse D stated the resident's wheelchair was cleaned on night shift, but staff should make sure the resident's wheelchair and cushions were cleaned after each meal. The facility's Resident Rights and Responsibilities policy, dated 5/1/19, documented the facility would ensure the residents' right to a dignified existence, self-determination and person-centered care with access to persons and services inside and outside the facility. The facility would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. The facility failed to provide cares in a manner that promoted and enhanced quality of life, dignity, and respect for Resident #3, who's wheelchair, wheelchair cushion, and foot pedal cushion were dirty with crumbs and dried food substances.

The facility reported a census of 28 residents. The sample included 3 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to protect, investigate, and report verbal abuse from direct care staff O when this staff spoke inappropriately to resident #2 on 8/10/16 and in front of resident #3 on 8/28/16, and again when direct care staff P spoke inappropriately to resident #4 on 10/12/16. Furthermore, direct care staffs O and P continued to work, providing direct resident care until 10/25/16. This deficient practice placed the residents of the facility in immediate jeopardy. Findings included: - The signed physician's orders [REDACTED].#2 dated 10/19/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The Quarterly MDS dated [DATE] documented the resident experienced short term and long term memory problems. The Care Area Assessment date 5/10/16 for cognition documented the resident suffered from a cognitive impairment. The care plan dated 8/10/16 documented the resident had severely impaired cognition, but failed to direct staff with interventions needed to care for the resident. Review of direct care staff O's employment file documented staff O received one on one training for an incident on 8/10/16 when staff O inappropriately spoke to resident #2. Review of the clinical record for resident #2 from 1/1/16 through 10/18/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 8/10/16 through the onsite survey day. On 10/25/16 at 8:19 AM, the resident laid in bed with his/her eyes closed. On 10/25/16 at 2:17 PM, administrative nursing staff D stated he/she received report of the 8/10/16 incident on 8/11/16. He/she provided direct care staff O with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received in-service education to protect the residents when staff abuse occurred. On 10/25/16 at 4:27 PM, direct care staff Q stated he/she and direct care staff O provided care to resident #2 on 8/10/16, at which time he/she heard staff O say, You f***ing b****! to the resident. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to investigate and report verbal abuse from direct care staff O for this cognitively impaired resident after an incident on 8/10/16. Direct care staff O continued to work at the facility providing direct care to the residents after the incident of verbal abuse, placing the residents of the facility in immediate jeopardy. - The signed physician's orders [REDACTED].#3 dated 10/19/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition). The Quarterly MDS dated [DATE] documented a BIMS score of 7, which indicated severely impaired cognition. The Care Area Assessment date 3/13/16 for cognition documented the resident suffered from cognitive impairment due to advanced [MEDICAL CONDITION]. The care plan dated 8/24/16 documented staff reoriented and cued the resident as needed. Review of direct care staff O's employment file documented staff O received online training for an incident on 8/28/16 when staff O inappropriately spoke in front of resident #3, stating, He's/she's your problem now. Review of the clinical record for resident #3 from 1/1/16 through 10/18/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 8/28/16 through the onsite survey day. On 10/25/16 at 8:07 AM, the resident sat in a wheelchair at the breakfast table. He/she was alert and calm. On 10/25/16 at 2:17 PM, administrative nursing staff D he/she received report of the 8/28/16 incident on 8/29/16. He/she provided direct care staff O with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received education to protect the residents when staff abuse occurred. On 10/25/16 at 5:57 PM, direct care staff R stated he/she and direct care staff O provided eating assistance to resident #3. Resident #3 liked to push himself/herself away from the dining room table. Staff R said staff O spoke inappropriately in front of resident #3, stating, He's/she's your problem now. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to investigate and report verbal abuse from direct care staff O for this cognitively impaired resident after an incident on 8/28/16. Direct care staff O continued to work at the facility providing direct care to the residents after the incident of verbal abuse, placing the residents of the facility in immediate jeopardy. - The signed physician's orders [REDACTED].#4 dated 9/17/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Sets ((MDS) dated [DATE] and 7/19/16 documented a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition). The Significant Change MDS dated [DATE] documented a BIMS score of 7 (less than 7 indicated severely impaired cognition). The Care Area Assessment date 7/19/16 for cognition documented the resident had poor memory and safety awareness, and needed cues from staff. The care plan dated 8/24/16 documented the resident had moderately impaired cognition, but failed to direct staff with interventions needed to care for the resident. Review of the Concern/Complaint log dated 6/14/16 to 10/13/16 documented concerns with care for this resident by a staff member. It noted the concern was resolved through discussion and education. Review of the clinical record for resident #4 from 4/15/16 through 10/12/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 10/12/16 and through the onsite survey day. On 10/25/16 at 8:30 AM, direct care staff P provided assistance to residents in the dining room. On 10/25/16 at 7:00 PM, direct care staff S stated he/she and direct care staff P provided care to resident #4, at which time he/she heard staff P speak inappropriately in front of resident #4 when he/she said, I don't see why some residents have to suffer. I just wish they would die. On 10/25/16 at 7:45 PM, administrative nursing staff D stated he/she received report of 10/12/16 incident on 10/13/16. He/she provided direct care staff P with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received education to protect the residents when staff abuse occurred. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to investigate and report verbal abuse from direct care staff P for this cognitively impaired resident after an incident on 10/12/16. Direct care staff P continued to work at the facility providing direct care to the residents after the incident of verbal abuse, placing the residents of the facility in immediate jeopardy. Failure to protect the residents by allowing the staff members to continue to work, providing direct resident care, after these incidents, placed the residents of the facility in immediate jeopardy. The facility abated the immediate jeopardy on 10/27/16 at 7:00 PM by initiating the following: Direct care staffs O and P were suspended pending the outcomes of the investigations; all staff in-service on the elements of the guideline ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The deficiency remained at a scope and severity of an F.

The facility reported a census of 28 residents. The sample included 3 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to provide an environment free of verbal abuse from direct care staff O when this staff spoke inappropriately to resident #2 on 8/10/16 and in front of resident #3 on 8/28/16, and again when direct care staff P spoke inappropriately to resident #4 on 10/12/16. Furthermore, direct care staffs O and P continued to work, providing direct resident care until 10/25/16. This deficient practice placed residents #2, #3, and #4 in immediate jeopardy. Findings included: - The signed physician's orders [REDACTED].#2 dated 10/19/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition. The Quarterly MDS dated [DATE] documented the resident experienced short term and long term memory problems. The Care Area Assessment date 5/10/16 for cognition documented the resident suffered from a cognitive impairment. The care plan dated 8/10/16 documented the resident had severely impaired cognition, but failed to direct staff with interventions needed to care for the resident. Review of direct care staff O's employment file documented staff O received one on one training for an incident on 8/10/16 when staff O inappropriately spoke to resident #2. Review of the clinical record for resident #2 from 1/1/16 through 10/18/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 8/10/16 through the onsite survey day. On 10/25/16 at 8:19 AM, the resident laid in bed with his/her eyes closed. On 10/25/16 at 2:17 PM, administrative nursing staff D stated he/she received report of the 8/10/16 incident on 8/11/16. He/she provided direct care staff O with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received in-service education to protect the residents when staff abuse occurred. On 10/25/16 at 4:27 PM, direct care staff Q stated he/she and direct care staff O provided care to resident #2 on 8/10/16, at which time he/she heard staff O say, You f***ing b****! to the resident. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to provide an environment free from verbal abuse from direct care staff O for this cognitively impaired resident. - The signed physician's orders [REDACTED].#3 dated 10/19/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired cognition). The Quarterly MDS dated [DATE] documented a BIMS score of 7, which indicated severely impaired cognition. The Care Area Assessment date 3/13/16 for cognition documented the resident suffered from cognitive impairment due to advanced [MEDICAL CONDITION]. The care plan dated 8/24/16 documented staff reoriented and cued the resident as needed. Review of direct care staff O's employment file documented staff O received online training for an incident on 8/28/16 when staff O inappropriately spoke in front of resident #3, stating, He's/she's your problem now. Review of the clinical record for resident #3 from 1/1/16 through 10/18/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 8/28/16 through the onsite survey day. On 10/25/16 at 8:07 AM, the resident sat in a wheelchair at the breakfast table. He/she was alert and calm. On 10/25/16 at 2:17 PM, administrative nursing staff D he/she received report of the 8/28/16 incident on 8/29/16. He/she provided direct care staff O with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received education to protect the residents when staff abuse occurred. On 10/25/16 at 5:57 PM, direct care staff R stated he/she and direct care staff O provided eating assistance to resident #3. Resident #3 liked to push himself/herself away from the dining room table. Staff R said staff O spoke inappropriately in front of resident #3, stating, He's/she's your problem now. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to provide an environment free from verbal abuse from direct care staff O for this cognitively impaired resident. - The signed physician's orders [REDACTED].#4 dated 9/17/16 included [DIAGNOSES REDACTED]. The Significant Change Minimum Data Sets ((MDS) dated [DATE] and 7/19/16 documented a Brief Interview for Mental Status (BIMS) score of 5, which indicated severely impaired cognition). The Significant Change MDS dated [DATE] documented a BIMS score of 7 (less than 7 indicated severely impaired cognition). The Care Area Assessment date 7/19/16 for cognition documented the resident had poor memory and safety awareness, and needed cues from staff. The care plan dated 8/24/16 documented the resident had moderately impaired cognition, but failed to direct staff with interventions needed to care for the resident. Review of the Concern/Complaint log dated 6/14/16 to 10/13/16 documented concerns with care for this resident by a staff member. It noted the concern was resolved through discussion and education. Review of the clinical record for resident #4 from 4/15/6 through 10/12/16 failed to document any incidents of staff mistreatment of [REDACTED]. Review of the staffing schedules for August 2016, September 2016, and October 2016 documented staff O continued to work after 10/12/16 and through the onsite survey day. On 10/25/16 at 8:30 AM, direct care staff P provided assistance to residents in the dining room. On 10/25/16 at 7:00 PM, direct care staff S stated he/she and direct care staff P provided care to resident #4, at which time he/she heard staff P speak inappropriately in front of resident #4 when he/she said, I don't see why some residents have to suffer. I just wish they would die. On 10/25/16 at 7:45 PM, administrative nursing staff D stated he/she received report of 10/12/16 incident on 10/13/16. He/she provided direct care staff P with education. Staff D expected staff to immediately report all incidents of abuse, neglect, and exploitation to their supervisor. Staff D further stated staff received education to protect the residents when staff abuse occurred. The facility's policy, ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The policy defined verbal abuse as use of any oral language that willfully included derogatory terms. The facility failed to provide an environment free from verbal abuse from direct care staff P for this cognitively impaired resident. These incidents placed residents #2, #3, and #4 in immediate jeopardy. The facility abated the immediate jeopardy on 10/27/16 at 7:00 PM by initiating the following: Direct care staffs O and P were suspended pending the outcomes of the investigations; all staff in-service on the elements of the guideline ANE: Abuse Prevention, Intervention, Reporting and Investigation - Staff treatment of [REDACTED]. The deficiency remained at a scope and severity of a G.

The facility had a census of 27 residents. The sample included 10 residents. Based on observation, record review and interview the facility failed to implement interventions to prevent the development of a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, often includes undermining and tunneling) facility acquired pressure ulcer for 1 of 1 residents reviewed for pressure ulcers. (#2) Findings included: - The 1/17/14 physician's orders [REDACTED]. glucose, there's not enough insulin made or the body can t respond to the insulin), and dementia (progressive mental disorder characterized by failing memory, confusion). Resident #2's quarterly (MDS) Minimum Data Set 3.0 assessment, dated 7/18/13, indicated the resident had short and long term memory problems, severe cognitive impairment, required total assistance of 2 staff with bed mobility, transfer and toilet use, and range of motion impairment for his/her lower extremities. The MDS further indicated the resident at risk for pressure ulcers, had no unhealed pressure ulcers, had a pressure reducing device for the chair and bed, and a turning/repositioning program. The significant change MDS, dated [DATE], indicated the resident now had one stage IV pressure ulcer which measured 5.4 (cm) centimeters x 3 cm x 0.8 cm. The 9/27/13 (CAA) Care Area Assessment for falls indicated on 8/31/13 at 12:15 AM the staff found the resident lying on the floor mat next to his/her bed with an open area to the right side of his/her knee which measured 4 cm x 1.5 cm. The CAA for pressure ulcers, dated 9/27/13, indicated the resident developed a stage IV pressure ulcer on the posterior right knee with 80% slough (stringy mass that may or may not be firmly attached to surrounding tissue) and 20% granular tissue (shiny red and granular in appearance) in the wound bed with a small amount of serosanguineous drainage (tinged with blood) with tunneling at 3 o'clock. The CAAs revealed the resident was compromised with a [DIAGNOSES REDACTED]. The CAA stated the resident was immobile, required staff to turn and reposition him/her every 2 hours, and he/she had bowel and bladder incontinence. The 7/24/13 care plan indicated the resident required 2 staff assistance with transfers, using a mechanical lift, dressing, personal hygiene, toileting needs and bed mobility. The care plan indicated the resident had a foam pressure reducing/relieving mattress, staff were to assist the resident to reposition every 2 hours when he/she was in bed and every hour when he/she was in the chair and as needed. The care plan stated a licensed nurse was to perform a weekly skin assessment, and the certified nurse's aides were to monitor the resident's skin daily and report any change in the resident's skin to the charge nurse. The 4/24/13 laboratory results indicated the resident's [MEDICATION NAME] (a blood test used to measure the amount of protein in the blood which is necessary for healing and is used in part to determine a person ' s nutritional status) of 3.4 (3.4 - 5) and total protein of 7 (6.4-8.2). The 7/11/13 physician's orders [REDACTED]. The 7/17/13 Braden Scale for predicting pressure ulcer risk, had a score of 10, which indicated the resident at high risk for development of a pressure ulcer. The 8/31/13 treatment record directed the staff to check the dressing on the right side of the resident's right knee daily and to make sure the dressing was dry and intact and the wound area without redness or heat. Staff initialed the treatment record on each shift from 8/31/13 to 9/13/13 when the staff documented the area healed. Review of the September bath record revealed the resident was given a bath on 9/16, 9/19 and 9/23/13. The 9/19/13 weekly skin assessment indicated the resident had no skin issues. The 9/23/13 at 4:07 PM, nurse's note indicated the resident had a stage IV pressure ulcer on the posterior right knee with tunneling noted at 3 o'clock and the staff notified the primary physician and the family. The 9/23/13 physician's orders [REDACTED]. The 9/27/13 physician's progress note stated the facility had contacted him/her with concerns that the resident had an open area behind his/her right knee that now had purulent (containing, discharging or causing the production of pus) green drainage and was warm to touch. The resident winced when staff evaluated his/her right leg and staff noted an open area to the back of the resident's right knee with mild redness surrounding the open area, some bleeding present, and staff reported tunneling present. The wound was cultured and the resident was placed on Keflex (an antibiotic), 500 (mg) milligrams, orally (TID) three times a day for 7 days for staphlococcus (Gram-positive bacteria) infection. The 10/24/13 laboratory results indicated the resident's [MEDICATION NAME] of 3.2 (3.4-5) and total protein of 7.1 (6.4-8.2). The 12/26/13 laboratory results indicated the resident's [MEDICATION NAME] of 2.5 (3.4-5) and total protein of 6.3 (6.4-8.2). On 1/29/14 at 8:49 AM, Nurse A pushed the resident into his/her room in a Broda chair (specialized wheelchair with the ability to tilt and recline) after gathering the dressing change supplies. Nurse Aide B tilted the Broda chair back so the resident reclined in the chair. Nurse A washed his/her hands and handed Nurse Aide B a pad to put under the resident's legs. Nurse A arranged the dressing supplies on a bedside table, applied hand gel and gloves. Nurse A told the resident he/she was going to remove the old dressing which the resident tolerated well. Nurse A threw the soiled dressing with a moderate amount of brownish drainage into the trash, removed gloves, applied hand gel and clean gloves. Observation revealed an open area to the back of the resident's right knee, approximately the size of a nickel, the wound bed was pink with a whitish edge, and the tissue around the wound was pink. Nurse A cleansed the wound with Saf clens and gauze sponges then loosely packed the tunneling with [MEDICATION NAME] Ag rope (a specialized dressing for packing wound cavities)and the resident grimaced and contracted his/her legs. Nurse A applied [MEDICATION NAME] foam dressing over the site and taped it in place. Nurse A asked the resident if his/her pain was okay and he/she stated it was fine. Both staff pulled the resident up in his/her chair with the positioning pad, placed a microfiber pillow behind his/her knees, a pillow between his/her knees and a pillow under his/her feet on the foot rest. On 1/29/14 at 5:52 PM, Nurse Aide C stated he/she looked at the resident's skin when providing bedtime cares. Nurse Aide C stated the nurses performed weekly skin assessments and the resident's knees were almost always contracted. Nurse Aide C stated it was very difficult to view the skin on the back of the resident's knee. On 1/30/14 at 9:19 AM, Nurse Aide D stated the resident received passive range of motion exercises in the morning and he/she did not notice any skin issues on the back of the resident's knees. On 1/30/14 at 9:51 AM, Administrative Nurse F stated the resident had an abrasion on his/her right knee from falling out of bed, and to keep the dressing in place, the staff used tubifast (a lightweight, tubular bandage that encircles the leg and is used to keep a dressing in place). Administrative Nurse F stated the resident had contractures to his/her knees, was constantly pulling his/her knees tighter, and does not fully extend his/her knees. On 1/30/14 at 11:44 AM, Nurse E stated the staff provide a weekly skin assessment of the residents after their baths and he/she could not recall any reason why tubifast would have been used after the abrasion on the right medial knee was healed. On 1/30/14 at 1:27 PM, Nurse Aide B stated he/she was getting the resident ready for his/her whirlpool on 9/23/13 and when he/she went to remove the tubifast from the resident's knee, it was stuck to the back of the resident's knee with dried blood. Nurse Aide E brought the charge nurse in and he/she removed the tubifast. Nurse Aide E stated the wound to the front of the resident's knee was healed and he/she was not sure why the resident still had the tubifast on. On 1/30/14 at 3:04 PM, Administrative Nurse F stated the staff continued the usage of the tubifast after the abrasion on the front of the resident's knee healed, to prevent the resident's knees from rubbing together due to the contractures. On 2/3/14 at 1:39 PM, Physician G stated the stage IV pressure ulcer could possibly have been caused by the tubifast, but was difficult to determine and would expect the facility staff to monitor the resident's skin under the tubifast at least twice daily. Review of the July 2013 Skin Integrity: Nursing Intervention and Wound Treatment Guidelines for Health Care Center policy directed the facility to identify residents at risk for pressure ulcer development and implement pressure ulcer preventative measures to maintain intact skin. The policy also stated a pressure ulcer is defined as any lesion caused by unrelieved pressure, which results in damage of underlying tissues and is staged to classify the degree of tissue damage. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. The policy listed the following as major risk factors for developing pressure ulcers: alterations in sensation or response to discomfort (loss of feeling, comatose or paralysis), alterations in mobility (chair, bedfast, physical restraint, pain, or contracture), exposure to friction or shearing forces (unable to pull self up in bed, involuntary muscle movements that cause rubbing against sheets), decreased cognition or level of consciousness, generalized physical deconditioning, inactivity or recent decline in ADL's, and conditions/diseases: diabetes, [MEDICAL CONDITION], vasculitis/collagen vascular disease, [MEDICAL CONDITION] or other dementias, depression/[MEDICAL CONDITION]. The facility failed to adequately assess and reassess Resident #2's right knee after applying a dressing to an abrasion and to implement preventative measures and the resident developed a Stage IV facility acquired avoidable pressure ulcer.